Dermatology Flashcards
Fitzpatrick Skin Types
Fitzpatrick Skin Types
- White
- Never tans - White
- Usually burns - White
- Sometimes burns - Moderate brown
- Rarely burns - Dark brown
- Very rarely burns - Black
- Does not burn
Dermatology
- Family histories
Dermatology FHx
- Skin disease
- Atopy
- Autoimmune
Dermatology
- SHx
Dermatology SHx
- Occupation
- Sun exposure
- Contactants - Improvement when away from work
Dermatology History
- Drug Hx
Dermatology DHx
- Regular/recent
- Systemic/topical
- Where
- How much
- How long
Dermatology exam
- SCAM
Dermatology SCAM
S - ite
C - colour
A - ssociated changes
M - orphology
Dermatology
- ABCD
Dermatology ABCD
A - ssymetry
B - order
C - olour
D - iameter
Atopic Eczema
- Mx
Atopic Eczema - Mx
- Irritiant Avoidance
- Soap/detergents, oveheating/rough clothing
- Infections, pets, pollen, HDM, stress - Emollients
- Topical CSTs
- Daily
- Face more mild than body - Antihistamines
- Pruritus
Suspected Melanoma
- Mx
Suspected Melanoma
- Refer on urgent pathway if:
- > 3 points
- 2 points for major: Size/shape/colour change irregularity
- 1 point for minor: 7mm/inflammation/oozing/sensation change - Suspected nodular melanoma
- Dermoscopy is suggestive
Eczema
- Emmolients
- Role
- Ingredients
- Escalation
Emmolients
- Medical moisturisers
- Fats
- eg. paraffin
- and water - Additional antimicrobials
- Rehydrates skin
- re-establishes lipid layer - Lotions-> creams -> ointments
Eczema
- Emolient use
- Dosing
- Timing
- Dispenser
- Risks
- Terminating
Eczema
- Emolient use
- Liberal and frequent
- BD-QDS - After washing to trap moisture
- Pump dispensers
- Avoid bacteria - Paraffin is flammable
- Continue after flare
Eczema steroids
- Escalation
Eczema steroids
- Escalataion
- Hydrocortisone
- Euvomate
- Clobetasone butyrate - Betnovate
- Betamethasone valerate - Dermovate
- Clobetalsol propionate
Eczema
- Sleep disturbance Mx
Eczema Sleep disturbance
- Antihistamines
Topical steroids
- Local SEs
Topical CSTs
- Local SEs
- Skin atrophy
- Telangiectasia
- Striae
- Acne
- Perioral dermatitis
- Allergic contact dermatitis
- Exacerbate skin infections
Topical steroids
- Systemic SEs (PO)
Steroid systemic SEs
- Cushing’s
- Immunosuppression
- HTN
- DM
- OP
- Cataracts
- Steroid-induced psychosis
- Fluid retention
Topical steroids
- Patient-friendly dosing
Topical steroids
- Patient-friendly dosing
- Finger Tip Units
- Eg.
- Face and neck - 2.5 FTUs
- Arm -3FTUs
- Leg - 6FTUs
- Trunk - 7FTUs
Eczema
- Maintenance mx
Eczema
- Maintenance mx
- Emollients
- Low-potency steroids
- Dressings
- Dry/medicated bandages
- Wet wraps (not for wet eczema)
Eczema
- Frequent flare-up management
Eczema
- Frequent flare-up management
- Check compliance
- Steroid weekend regime
- Weekly 2/7 of potent steroids - Consider alternatives
- eg. Protopic (Tacrolimus) - Skin swab/nasal swabs
- Bactroban if staph positive - Consider allergic dermatitis
- Immunomoddulators
- eg. Protopic (Tacrolimus)
Topical Calcineurin Inhibitors
- 2 Drugs
- 2 Uses
- 3 SEs
Topical Calcineurin Inhibitors
- Examples
1. Protopic (tacrolimus ointment)
2. Elidel (pimecrolimus cream) - Use
1. Atopic dermatitis
2. Preventing flare-ups - SEs
1. Local skin irritation
2. Area risk of HSV
3. Worsens acute infections
Scalp eczema
- Tx
Scalp eczema tx
- Tar-based shampoo
- <18mo, emollient bath oil - Topical steroids (water-based scalp application)
- Betacap
- Sebco ointment for scale removal
Dermatology
- Use of methotrexate
- Uses
- Dosing
- SEs
Dermatology - methotrexate
- 2 Uses
1. Psorisis
2. Eczema - Dosing
1. PO/SC
2. Folic acid - separate day! - SEs
1. GI upset
2. Mouth ulcers
- Fatigue/anaemia
- Liver
- Lung fibrosis
- BM suppression - screen for infections/live vaccines
- Teratogenic - contraception (male and female!)
- Interactions
- Trimethoprim
Methotrexate
- Initiating
- Monitoring
Methotrexate
- Initiating
1. Pregnancy test
2. FBC
3. U&E/LFT - Monitoring (2-3 months)
- FBC
- U&E
- LFTs
Azathioprine
- Dermatology
- Uses
- SEs
- Screening/monitoring
Azathioprine
- Dermatology
- Uses
1. Atopic eczema - SEs
1. BM suppression
2. Allergic reaction
3. GI upset
4. Prolonged use - Skin cancer
- Lymphoma
- Screening/monitoring
1. TPMT test
2. Monitor FBC,LFT,U&E
3. Avoid live vaccines
Ciclosporin
- Dermatology
- Uses
- SEs
- Monitoring
Ciclosporin
- Dermatology
- Uses
1.Psoriasis
2. Atopic eczema - SEs
1. Gingival hyperplasia
2. GI Upset
3. Fatigue
- Tremor
- Excessive hair growth
- Monitoring
1. No live vaccines
2. No prgenancies
3. No breast feeding
4. Drug interactions
Comedonal acne
- First line
- SEs
Comedonal acne
- Mx
1st line — Topical retinoid
- Adapelene
- Isotretinoin
+ Benzoyl peroxide - Avoid in pregnancy
- Dries skin and irritates
Papular/pustular acne
- Mx
Papular/pustular acne
- Mx
Combination
- Epiduo
(adapelene +BPO) - Duac
(clindamycin +BPO)
Refractive acne
- Mx
Refractive acne Mx
- Systemic ABx
- Tetracycline
- Not in children or pregnancy - Macrolides
- Erythromycin/clarythromycin - Trimethoprim
- Used in young children
- Some bacterial resistance - Primary care
- Stop oral ABx after 3mo
- See dermatologit
Female: Moderate-severe acne
- GP Mx
- ADRs
Female acne - moderate-severe
- Dianette
- Cyproterone acetate
+ ethinyloestradiol - Increased risk of VTE
- CI’d in FHx of VTE
- CI’d in past VTE
- Not indicated as sole OCP
Acne
- Referal criteria
Acne
- Referal criteria
- Severe acne
- Moderate acne
- Partially responsive
- Scarring
- Hyperpigmentation - Psychological symptoms
Retinoids
- ADRs
Retinoids
- ADRs
- Dry skin/dry lips/ dry eyes
- Fragile skin
- Avoid waxing - Increased infection risk
- Slower healing
- Increased sun sensitivity
- LFT derangement
- Cholesterol and tri-glycerides - Myalgia/arthralgia
- Depression/DSH/Suicide
- Teratogenic
- Acitretin (3 years)
Psoriasis
- Mx
Psoriasis Mx
- Consider co-morbidities
1. Psoriatic arthritis - Rheumatology referral
2. CVD - Drugs
1. Emollients - Reduce scale
2. Flare-ups - Vitamin D
eg. Dovobet/Enstilar foam 8-12/52 - Moderate steroid eg. Eumovate 1-2/52
Psoriasis
- Vitamin D analogues
- Names
- Role
- SEs
Psoriasis Vitamin D analogues
- Drugs
1. Calcipotriol
2. Tacalitol
3. Calcitriol - Role
1. Regulate immune system
2. Slow overgrowth - SEs
1. Irritate sensative areas
2. Hypercalcaemia
3. Not recommended during preganancy.breast feeding
Psoriasis
- 2nd line referral
Psoriasis second line
- Phototherapy
- Acitretionin
- Methotrexate
- Ciclosporin
- PD4 inhibitor
- Apremilast - Dimethyl fumerate
Psoriasis
- Phototherapy
- Timing
- Types
Psoriasis Phototherapy
- Timing
1. Twice weekly
2. 15-30 treatments - Types
1. Narrowband UVB - Severe psoriasis and eczema
- PUVA (deeper reaching)
- Psorelan +UVA
- Psoriasis, vitiligo, cutaneous T-cell lymphoma
Dermatology Phototherapy
- ADRs
Dermatology Phototherapy
- ADRs
- Redness/discomfort
- Dry and itchy
- Folliculitis
- Poly-morphic light erruption (rash)
- Cold sores
- Worsening of skin disease
- Nausea
- From PUVA psoralen - Premature aging/skin cancer
Dermatology
- Apremilast
- Mechanism
- ADRs
Dermatology - Apremilast
- Mechanism
1. PDE4 i (Phosophodiesterase 4 i)
2. Skin inflammatory processes - ADRs
1. GI upset
2. Headache/insomnia
3. Tiredness/muscle pain
4. Resp infections
- Avoid pregnancy/live vaccines
Dermatology
- Dimethyl fumerate (fumaric acid)
- Mechanism
- SEs
Dimethyl fumerate (fumaric acid)
- Mechanism
1. FAE acts on immune system - SEs
- GI upset
- Headache
- Flushing
- Monitor LFT, U&E, urine dip, FBC
- Leukoencephalopathy - Avoid pregnancy/breastfeeding
Psoriasis
- Biologics
- Use
- Names
- SEs
Psoriasis Biologics
-Use
1. Methotrexate and ciclosporin no effect/tolerated
2. Large impact disease
- Drugs
1. Ustekinumab
2. Adalimumab
3. Secukinumab
- Infliximab
- SEs
- TB/Hep BC/HIV/ VZV screen
- No live vaccines
Scalp psoriasis
- Mx
Scalp psoriasis
- Mx
- Potent CSTs
- Betacap 4 weeks - Descaling
- Diprosalic - Potent CTs with Calcipotriol
- Dovobet 4 weeks - Very potent CST
- Etrivex shampoo 4 weeks
- Sebco scalp ointment OD/BD
Venous ulcer
1. Sx
2. Mx
Venous ulcer
- Sx
1. Well defined, below knee
2. Brown edges, granulation tissue
3. Itchy - Mx
1. Compression stockings - Check ABPI with doppler
Nail dystrophy
- Causes
Nail dystrophy
- Causes
- Melanoma
- Trauma
- Fungal infection
- Psoriasis
Melanoma
- Prognostication
Melanoma
- Prognostication
- Breslow thickness
Tinea pedis
- common organism
- Treatment
Tinea pedis
- common organism
Trichophyton rubrum - Treatment
Fluconazole
Perioral dermatitis
- Distribution
- Treatment
Perioral dermatitis
- Distribution
1. Tiny blisters - red, itchy
- tingle, burn
2. Muzzle area
(Triggered by steroids) - Treatment
1. Stop using cleanses/steroids
2. Non steroids - Elidel cream (Pimecrolimus)
- Minocycline
SCC
- Poor prognosis sites
SCC
- Poor prognosis sites
- Lips
- Ears
- Eyes
Bullous pemphigoid
- Blisters
- Treatment
Bullous pemphigoid
- Blisters
Tense
Some empty - Treatment
0. Autoimmune condition
1. Topical Steroids (Dermovate)
2. Doxycycline
3. Prednisolone (0.5mg/kg) - until no new blisters
High dose steroids
- protection
High dose steroids
- protection
- PPI
- Steroid card
- COVID warning - Bone protection
Psoriasis
- appearance
- treatment
Psoriasis
- appearance
0. Demarcated scaly plaques
1. Extensors
2. Ears
3. Scalp
4. Natal cleft
5. Nail pitting - treatment
1. Retinoids
Lesions
- 5 Ss
Lesions
- 6 Ss
1 Site
2 Shape
3 Size
4 Shade
5 Surface
6 Surrounding skin
Acne
- Combination gels
Acne
- Combination gels
- Duac
- BP
- Clindamycin - Epiduo
- BP
- Adapalene (retinoid)
Roaccutane
- ADRs
Roaccutane (Isotretinoin)
- ADRs
- Dry eyes, skin, nose
- Thin and breakable - Sore throat/mouth
- Headaches
- Teratogenic
- COCP - Low mood
Eczema
- Mx ladder
Eczema
- Mx ladder
- Emollients
- Topical csts
(mild, mod, potent) - Topical calc. i.
- Tacrolimus/pimecrolimus - Bandages
- Phototherapy
- Oral CSTs
Psoriasis
- Common Types
Psoriasis
- Types
- Plaque
- psoriasis vulgaris - Scalp psoriasis
- Nail psoriasis
- Guttate psoriasis
- <1cm on trunk, limbs scalp
- Post strep - Inverse psoriasis
- flexural
Psoriasis
- Four less common types
Psoriasis
- Four less common types
- Pustular psoriasis
- Generalised pustular psoriasis
- Von Zumbusch psoriasis - Palmoplantar pustulosis
- Erythrodermic psoriasis
- Nearly all the skin
Lentigo maligna
- Features
- Tx
Lentigo maligna
- Features
1. Slow growing brown patch
2. Evolves into melanoma
3. Commonly on the face
4. Commonly on older people
Nodular melanoma
- Mx
Nodular melanoma
- Mx
Stage 0
- Consider Imiquimod
- 0.5cm margin excision
- Repeat bipsy
Stage 1
- 2cm margin excision (1 if disfiguring)
Stage 2
- 2cm margin excision
Stage 3
- Excision
- Adjuvant chemo
- No adjuvant radio unless risk outweighs harms
Stage 4
- MDT
- Surgery/ablation
- Brain surgery/radio
- Consider chemo/immnotherapy
(Nivolumab/ipilimumab)
Acral melanoma
- Features
Acral melanoma
- Features
- Palms, soles, fingernails/toenails
- Common in darker skin
Sub-ungal haematoma
- Features
- Mx
Sub-ungal haematoma
- Features
1. Pseudo hutchinson’s sign
2. Subungal blood - Mx
1. Follow up
Benign longitudinal melanonychia
- Features
- Mx
Benign longitudinal melanonychia
- Features
1. Thin
2. Multiple - Mx
1. Biopsy to r/o melanoma
Classic seborrheic keratoses
- Features
- Mx
Classic seborrheic keratoses
- Features
1. Brown ‘warty’ appearance - comedo-like openings
2. Milea-like cysts
3. Older person
4. Multiple similar lesions
5. Rough to touch
Non-melanoma skin cancer
- Two pre-malignant conditions
Non-melanoma skin cancer
- Pre-malignant conditions
- Actinic keratosis
- Bowen’s disease
- Pink patch
- Full thickness dysplasia
- In situ SCC
BCC
- Appearance
- Growth
- Ex
BCC
- Appearance
1. ‘Rodent ulcer’
2. Rolled pearly margin
- Translucent stroma production
- Well defined blood vessels
3. Morphoeic BCC
- indistinct edges
4. Superficial BCC
- Pink patch
- Similar to Bowen’s disease
5. Pigmented BCC
- Grey ‘bean-like’ structure
6. Slow growing
- Growth
1. Destruction
2. Can wrap around nerve - death from brain metastasis
- Ex
1. Good lighting and remove crust
MOHS
- Sites
- Process
MOHS
- Sites
1. Sensitive
2. Narrow margin - Process
1. LA
2. Horizonal cut
3. Frozen section
4. Margins - peripheral and deep
Picker’s Nodule
- Features
- Mx
Picker’s Nodule
- Features
- Intensely itchy
- Mx
1. Psychiatry
2.
Dermatofibroma
- Features
- Mx
Dermatofibroma
- Features
1. May mimic bcc, scc, melanoma
2. Firm nodules
3. Dimple sign - Pinch - and see dimple in the middle
- Mx
1. Observe
SCC
- Features
SCC
- Features
1. 1/5 Type 1,2 skin
- Can be painful
- Keratotic nodule
- Fleshy - can be ulcerated
- Rapidly growing
- Sun-exposed locations
- Ear helix
- Hand
- Actinic keratosis
arSCC
- Mimics
SCC
- Mimics (biopsy them)
- Viral warts
- inflamed squamous papillomas
- Keratin horn
- Painless and pruritis - Regressing keratocanthoma
- Painless
- Ulcerated
- Crateriform - Sebhorric keratosis
- Large
- Traumatised
- Inflammed - Lymphoedema nodule
- Granulation tissue
- Fluid - Giant comedone
Skin cancer
- Topical options
Skin cancer
- Topical options
- 5FU (Efudix)
- AK, Bowen’s disease - Diclofenac
- AK - Imiquimod (Aldara)
- Superficial BCC - Retinoids
Surgical excision options
Surgical excision options
- Standard wide excision
- pre-determined margins - MOHS
- Micrographic excision
- Layer by layer with staged mapping
Skin cancer
- Non-surgical procedures
Skin cancer
- Non-surgical procedures
- Photodynamic therapy (PDT)
- Photosensitiser attaches to dysplastic cells
- Shine a light
- Photosensitiser destroys cells - Cryotherapy
- Superficial lesions
- SK to AK, Bowen’s and Superficial BCC
Skin cancer
- Radiotherapy uses
Skin cancer
- Radiotherapy uses
- Older persons
- SCC (good response)
- BCC (less good response)
Metastatic skin cancer
- Systemic treatment
Metastatic skin cancer
- Systemic treatment
- Immune therapy
Sun behaviour
- Incl sun screen
Sun behaviour
- Incl sun screen
- Avoid sun
- Sunscreen
- 15-30 minutes before exposure
- 2-hourly reapplication
- 30mls + for adults - SPF
- 4 - 75% blockage
- 15 - 93% blockage
- 30 - 96% blockage
Actinic keratosis
- 5-FU/Imiquimod treatment progress
Actinic keratosis
- 5-FU/Imiquimod treatment progress
- Application
- 1-2 weeks later eruption
- 6-7 weeks later recovery
Cryosurgery
- Process
Cryosurgery
- Process
- Liquid nitrogen
(-196ºC) - Ice crystals form
Skin cancer
- Surgical principles
Skin cancer
- Surgical principles
- Remove all cancer
- Prevent metastatic spread - No biopsies
- Wide-local excision
- 2mm margin where possible
- fully excised
- 3-1 ratio for elipse
- scar longer than patient expects
Pre-determined margins
- Melanoma
- SCC
- BCC
Pre-determined margins
- Melanoma
1. In situ (5mm)
2. <1mm thickness (1cm)
3. >2mm thickness (2cm) - SCC
4. 4-8mm - BCC
5. 3-5mm - Suspicious pigmented lesion
6. 2mm
Superficial spreading malignant melanoma
- Features
- Mx
Superficial spreading malignant melanoma
- Features
- Mx
Skin cancers
- 1 Key fact for diagnosis
- 2 Powerful risk factors
Skin cancers
1 Key fact for diagnosis
- Onset and rate of growth
2 RFs
- Sun exposure
- Genetics
Cancer layer origins
- BCC
- SCC
- Melanoma
Cancer layer origins
- BCC
1. Basal epidermis - SCC
- Epidermal squamous
- Melanoma
3. Epidermis
Skin cancer
- Proportions and referrals
- 2WW
- Routine
Skin cancer
- Proportions and referrals
- 2WW
- 10% melanoma
- 30% SCC - Routine
- 60% BCC
Melanoma
- Breslow and prognosis
Melanoma
- Breslow and prognosis
1mm - 100% 5YS
4mm - 60% 5YS
BCC
- Demoscopy signs
BCC
- Demoscopy signs
- Telangiectasia
- Tree-like trunky red vessels
Basal cell c
- Subtypes
Basal cell c
- Subtypes
- Superficial spreading BCC
- Patch - Nodular BCC
- Infiltrative/Scar-like BCC
BCC Treatments
- Non-surgical
- Surgical
BCC Treatments
- Non-surgical
1. Cryotherapy - Superficial BCC
- 99% 5 year cure
- Liquid nitrogen
- 20s, 30s gap, 20s
- Creams
- 5FU
- Imiquimod - PDT
- Sensitising cream
- Red light - Radiotherapy
- Surgical
- Curettage and cautery (24%)
- 90% cure - Excision (58%)
- 4-5mm margin
- <2% recurrence
SCC
- Dermoscopy
SCC
- Dermoscopy
- Keratin Patch
SCC
- Followup
- Low risk
- High risk
SCC
- Followup
- Low risk
- High risk
- 4-6 mo
- Lymphadenopathy
Melanoma
- most common age groups
Melanoma
- most common age groups
- 38% 45-65
- 20% 65-75
Benign lesions
- Features
Benign lesions
- Features
- Symmetry good
- Border regular
- Colour uniform
- Diameter (vague) >6mm
- Evolution
Melanoma
- Dermoscopy
Melanoma
- Dermoscopy
- Dysplastic colour
Melanoma
- Acral
- Lentigo
Melanoma
- Acral
1. Palms/soles
2. Eg. Sub ungual - Lentigo
1. Face/sun touched
Melanoma
- Margin paradox
Melanoma
- Margin paradox
- 2mm
- Further surgery with lymph nodes
- eg. 2cm
Melanoma
- Immunotherapies
Melanoma
- Immunotherapies
- IL2
- interferon alpha - Nivolumab
Imatinib
Melanoma
- Followup
Melanoma
- Followup
- Superficial
- 1 year
2.
Comedone
- Definition
Comedone
- Definition
- Plug in sebaceous follicle
- Contains
- sebum
- bacteria
- cellular debris - Open (blackhead)
- Closed (whitehead)
Dermatology
- Distributions
Dermatology
- Distributions
- Generalised
- All over the body - Widespread
- Localised
- One area only - Flexural/extensor
- Pressure areas
- sacrum, buttocks
- ankles, heels - Dermatomal/photosensative
Dermatology
- Koebner phenomenon
Dermatology
- Koebner phenomenon
- Site of trauma
- Linear erruption
Lesions
1. Target
eg.
2. Annular
eg.
Lesions
- Target
- Concentric circles
eg. erythema multiforme (immune eg. HSV) - Annular
- Circle/ring
eg. tinea corporis (ringworm)
Lesions
- Discoid/nummular
1. Description
example
- Discoid/nummular
- Round lesion/coin-shaped
- Discoid eczema
- Hypopigmentation in SLE
Erythema
- Pathophysiology
Erythema
- Pathophysiology
- Inflammation
- Vasodilation
Purpura
- Pathophysiology
- Types
Purpura
- Pathophysiology
- bleeding into skin
- bleeding into mucous membrane
- non-blanching - Types
- petechiae
- ecchymoses
Hypo-pigmentation
- Definition
- Example
Vitiligo
- Definition
- Example
Hypo-pigmentation
- Definition
1. Paler skin areas - Example
1. Pityriasis versicolor (superficial fungus)
Vitiligo
- Definition
1. Absence of melanin
- Example
2. Vitiligo (loss of melanocytes)
Hyper-pigmentation
- Broad Differentials
Hyper-pigmentation
- Broad Differentials
- Post-inflammatory
- Melasma
- Naevi
Melasma
- Pres
- Tx
Melasma
- Pres
1. Hormonal
2. UV
3. Malar region of darker skin - Tx
1. Retinoids (bleaching)
2. Bleaching/chemical peels
3. Laser/light therapy
4. Sun protection
- Macule
- definition
- example - Patch
- definition
- example
- Macule
- Flat area of altered colour
- eg Freckles - Patch
- Larger flat area of altered colour or texture
- eg vascular malformation (naevus flammeus/PW stain)
Raised lesions
- Papule
- Nodule
- Plaque
+examples
Raised lesions
- Papule
- Solid raised lesion
+ xanthomata - Nodule
- Solid raised lesion with deeper component
+ Pyogenic granuloma (telangiectaticum) - Plaque
- Palpable scaling raised lesion
+ Psoriasis
- Vesicle
- Bulla
- Pustule
- Abscess
- Vesicle
- Raised clear filled lesion
+ Acute hand eczema - Bulla
- Raised, clear filled lesion
+ Insect bite reaction - Pustule
- Pus-filled lesion
+ Acne - Abscess
- Localised accumulation of pus
+ Peri-ungal abscess (paronychia)
- Boil/furuncle
- Carbuncle
- Boil/furuncle
- Around/within follicle
- Staph infection - Carbuncle
- Adjacent hair follicles
- Staph infection
- Excoriation
- Lichenification
- Excoriation
- Trauma to epidermis
+Eczema - Lichenification
- Roughening of skin with markings
+ Chronic eczema
- Scales
- Crust
- Scales
- Flakes of stratum corneum
+ Psoriasis (silvery scales) - Crust
- Rough surface through epidermis
- Serum, blood, bacteria, debris
+ impetigo
- Ulcer
- Fissure
- Ulcer
- Loss of epidermis and dermis
- Heals with scar - Fissure
- Epidermal crack
+ Dryness/eczema
- Scar
- Striae
- Scar
- New fibrous tissue
- post-healing
+ keloid scar - Striae
- Linear area
- Purple -> Pink -> White
- Scar-like
+Steroid use/ growth /pregnancy
Scar
- Three classifications
Scar
- Three classifications
- Atrophic
- thinning - Hypertrophic
- within wound boundary - Keloidal
- beyond wound boundary
Hirsuitism vs Hypertrichosis
Hirsuitism vs Hypertrichosis
- Androgen dependent hair-growth
- in a female - Non-androgen dependent
- eg. pigmented naevi
Nails
- Clubbing
- Koilonychia
- Onycholysis
- Pitting
Nails
- Clubbing
- Loss of angle
- Posterior nail fold and nail plate - Koilonychia
- Spoon-shaped depression - Onycholysis
- Separation of distal end from nail bed
- Trauma, psoriasis, fungal, hyperthyroid - Pitting
- Punctate depressions
- Psoriasis, eczema, alopecia
Skin
- Skin appendages
Skin
- Skin appendages
- Hair
- Nails
- Sebaceous glands
- Sweat glands
Skin
- Four cell types
- Cell functions
Skin cells
- Keratinocytes
- Keratin barrier production - Langerhans’
- Antigens and T-Cell activation - Melanocytes
- Melanin UV protection - Merkel
- Nerve endings for sensation
Epidermis
- Layers
Epidermis
- Layers
- Basale
- Dividing cells - Spinosum
- Differentiating cells - Granulosum
- Keratohyalin + lipid - Corneum
- Keratin
Skin layers
- Sole and Palm
Skin layers
- Sole and Palm
- Lucidum
- Pale, compact keratin - Beneath Corneum
Dermis
- Main cell type
- Main proteins
Dermis
- Main cell type
1. Fibroblasts
2. Immune and appendages
3. Connective tissues
- Main proteins
1. Collagen (mainly)
2. Elastin
3. Glycosaminoglycans
Hair
- Three types
- Three growth cycles
Hair
- Three types
1. Lanugo (fetus)
2. Vellus (fine short)
3. Terminal (coarse long)
- Three growth cycles
1. Anagen (long; growth)
2. Catagen (short; regression)
3. Telogen (Resting; shedding)
Sebaceous glands
- Secretion
- Stimulation
- Pathologies
Sebaceous glands
- Secretion
1. Sebum
2. Pilosebaceous unit - Stimulation
1. Dihydrotestosterone from androgens
2. Starts at puberty - Pathologies
1. Sebum and bacterial colonisation
2. Gland hyperplasia
Sweat glands
- Stimulation
- Types
- Pathologies
Sweat glands
- Stimulation
1. Sympathetic nervous system - Types
1. Eccrine - Universal
2. Apocrine - Puberty onwards
- Axillae, areolae, genitalia, anus
- Bacterial action produces body odour
- Pathologies
1. Apocrine inflammation/infection - Hidradenitis suppurativa
- Eccrine overactivity
- Hyperhidrosis
Wound healing
- Stages
Wound healing
- Stages
- Haemostasis
- Vasoconstriction - Inflammation
- Vasodilation - Proliferation
- Granulation tissue
- Angio-genesis
- Re-epithelialisation - Remodelling
- Collagen fibre re-organisation
- Scar maturation
Erythema nodosum
- Presentation
Erythema nodosum
- Presentation
- Hypersensitivity Response
- Shins, most commonly
- Discrete tender nodules
- May become confluent - Lesions appear for two weeks
- Bruise-like discolouration on resolution
Erythema nodosum
- Causes
- Infection
- Inflammation
Erythema nodosum
- Hypersensitivity Response
- Infection
1. Group A Strep
2. TB
3. Chlamydia
4. Leprosy - Inflammation
1. Pregnancy
2. Malignancy
3. IBD
4. Sarcoidosis
Acute skin management
- Principles for:
- Erythema multiforme
- Stevens-Johnson Syndrome
- Toxic Epidermal Necrolysis - Complications
- Erythema multiforme
- Stevens-Johnson Syndrome
- Toxic Epidermal Necrolysis
- Management principles
1. Early recognition
2. Full supportive care - Complications
1. Mortality rates 5-12% SJS, >30% TEN
2. Sepsis
3. Electrolyte imbalance
4. Multi-system organ failure
Acute Skin Conditions
- Presentations
- EM
- SJS
- TEN
Acute Skin Pathologies
- Erythema multiforme
- Often unknown/Herpes Simplex/Drugs
- Acute self-limiting
- Mucosa limited to one surface only - SJS
- Muco-cutaneous necrosis
- At least two mucosal sites
- Limited or extensive skin involvement - TEN
- Drug-induced
- Extensive skin/mucosal necrosis
- Systemic toxicity
- Full thickness epidermal necrosis
- Sub-epidermal detachment
Erythema multiforme
- Presentation
Erythema multiforme
- Presentation
- Erythematous patches
- Evolving into target lesions - Often involves both hands
SJS
- Early Symptoms
SJS
- Early Symptoms
- Fever
- Flu-like symptoms
- Blistering
Acute Meningococcaemia
- Rash progression
Acute Meningococcaemia
- Rash progression
- Blanching maculo-papular rash
- Non-blanching purpuric rash
- Progression to ecchymoses
- Haemorrhagic bullae
- Tissue necrosis
Acute meningococcemia
- Close contact prophylaxis
Acute meningococcemia
- Close contact prophylaxis
- ABx
- Rifampicin
Erythroderma
- Causes
- Management
Erythroderma
- Causes
1. Skin disease (eczema/psoriasis)
2. Lymphoma
- Drugs
- Sulfonamides
- Gold
- Penicillin
- Allopurinol
- Captopril - Idiopathic
- Management
1. Underlying
- Emollients and wet-wipes
- Topical steroids
Eczema Herpeticum
- Pathology
- Presentation
- Management
Eczema Herpeticum
(Kaposi’s varicelliform eruption)
- Pathology
1. Atopic eczema or other exacerbation
2. Herpes simplex cause - Presentation
1. Widespread eruption
2. Crusted papules
3. Blisters and erosions - Management
1. Anti-virals (aciclovir)
2. Antibiotics for 2º infections
Necrotising fasciitis
- Causes
- Presentation
- Mx
Necrotising fasciitis
- Causes
1. Group A Strep
2. Anaerobes or aerobes
3. RFs - Abdo surgery/co-morbidities
- Presentation
1. Severe pain
2. Erythematous, blistering, necrotic skin
3. Systemic illness
4. Surgical crepitus/soft tissue gas - Mx
1. Urgent surgical referral
2. IV ABx
Erysipelas & Cellulitis
- Pathology
- Causes
-Management
Erysipelas & Cellulitis
- Pathology
1. Dermis and upper sub-cutaneous - Erysipelas
2. Deep sub-cutaneous tissue - Cellulitis
- Causes
1. Strep pyogenes
2. Staph a.
3. RFs: Immunosuppression, wounds, leg ulcers
-Management
1. ABx
- Fluclox/benpen
2. Supportive
- Elevation, dressings, analgesia
‘Scalded Skin’ Syndrome (staph)
- Pathology
- Presentation
- Mx
‘Scalded Skin’ Syndrome (staph)
- Pathology
1. Epidermolytic toxin
2. Ben-pen resistant staph (coag positive) - Presentation
1. Infancy/childhood
2. Scald-like skin - Large flaccid bullae
- Perioral crusting
- Intra-epidermal blistering
3. Painful lesions - Mx
1. Recovery in 5-7 days
2. ABx
eg. Resistant penicillin, erythromycin, cephalosporin
3. Analgesia
Fungal infection
- Site classifications
Fungal infection
- Site classifications
- Tinea Capitis
- Scalp ringworm - Tinea Corporis
- Itchy, circular/annular lesions - Tinea manuum
- Palmar scaling/dryness - Tinea unguium
- Nail discolouration, thickening, crumbling - Tinea cruris
- Groin and natal cleft - Tinea pedis
- Athlete’s foot - Tinea incognito
- Tinea treated inappropriately with steroids - Tinea versicolor/Pityriasis
- Upper trunk scales
- Malessezia furfur
Skin
- Fungal infection mx
Skin
- Fungal infection mx
- No steroids
- Tinea incognito - Topical agents
- terbinafine cream - Oral agents
- severe/widespread/nail
- itraconazole
Atopic eczema/dermatitis
- Causes
Atopic eczema/dermatitis
- Causes
- Primary genetic defect
- skin barrier function
- Filaggrin protein loss of function
- Exacerbating factors
- infections
- allergens
- sweating, heat, occupation, severe stress
Eczema
- Presenting morphology
- Acute
- Chronic
- Papular
Eczema morphology
- Acute
1. Itchy papules
2. Vesicles - Chronic
1. Dry scaly patches
2. Erythematous or grey/brown
3. Lichenification - Papular/follicular
1. Brown, grey, purple bumps
Phototherapy
- dosing units
Phototherapy
- dosing units
- J/Cm2
Pyoderma gangrenosum
- Aetiology
- Pres
- Mx
Pyoderma gangrenosum
- Aetiology
- Autoimmune
- Common in RA - Discrete ulcers
Oedematous, violaceous border - Topical potent steroids
- betnovate
- demovate
- Cyclosporin/cyclophosphamide
Punch biopsy
- Size
- Examples
Punch biopsy
- Size
1. <3mm
2. Full thickness - dermis
- Examples
1. AK
2. Pyoderma gangrenosum
Cyclosporin
- 5 Hs
Cyclosporin
- 5 Hs
- Hypertension
- Hyperkalaemia
- Hypertrichosis
- Hair loss
- Hypertrophy of gingiva
Shave biopsy
- Type
- Uses
Shave biopsy
- Type
- Scooping flat lesions - Uses
- Flat lesions
Incisional biopsy
- Type
- Uses
Incisional biopsy
- Type
1. Deep incision - Uses
1. Vascular structures
2. Not commonly used
Excision biopsy
- Type
- Uses
Excision biopsy
- Type
- Curative eg for skin cancers - Uses
- SCC
- BCC
- Melanoma
Breslow Thickness
1. Epidermis
2. Dermis
3. Hypodermis
Breslow Thickness
- Epidermis
- No stage (0)
- In situ melanoma
( - Bowen’s disease in SCC) - Dermis
- Depth of >1mm - 1cm margin
2-4mm - 1-2cm margin
4mm - 2 cm margin - Hypodermis
Melanoma
- Staging Ix
- Mx
Melanoma
- Staging Ix
1. Staging CT
2. PET CT - Mx
1. Surgery
2. Immunotherapy
- (Chemo-radio not useful)
Rosacea
- Types
- Pathology
Rosacea
- Types
- Papulopustular
- Rhino-phimatous
- Pathology
1. Vasodilatation
Papulopustular Rosacea
- Tx
Papulopustular rosacea
- Tx
- Metronidazole
- Oxytetracicline (3-6 mo)
- 15-20% Azelaic acid
- Topical Ivermectin (anti-fungal and anti-biotic)
Psoriatic arthritis
- Joint pattern
Psoriatic arthritis
- Joint pattern
- DIPJ
Acne in pregnancy
- Retinoids
Acne in pregnancy
- Oral and topical retinoids are highly teratogenic
- 6-12 mo course
- HCG test and LFTs too - High dose salicylates and hydroquinone also not used
- Low dose Azelaic acid is allowed
Potent topical corticosteroids
- Length of course
Potent topical corticosteroids
- Length of course
- 8 Weeks max
Psoriasis
- Treatment ladder
Psoriasis
- Treatment ladder
- Topical CST + Top D analogue
- Enstella - Top Vit D Analogue BD
- Top CST + Coal tar OD
- Dithranol + Dermatology
- Black liquid to soak plaques
- eg. PUVA and PUVB (immunosuppressive)
Guttate psoriasis
- Signs
- Pathology
Guttate psoriasis
- Signs
1. Raindrop lesions
2. Small scaly patches - Pathology
1. Post-viral/strep
Pitoriasis rosacea
- Signs
- Pathology
Pitoriasis rosacea
- Signs
1. Fur tree sign
2. Herald patch - Pathology
1. Post-viral
Topical steroid course
- Body
- Scalp
Topical steroid course
- Body
- 8 weeks - Scalp
- 4 weeks eg. Betnovate
Actinic keratosis
- Creams
Actinic keratosis
- Immunotherapy Creams
- Skin will get yellow, crusty, and peel
- Aldara
- Contains imiquimod - Effedex
- Contains 5FU
Mohs surgery
- Indications
- Technique
Mohs surgery
- Indications
- Delicate places
- Visible places
- Less disfiguring
- Technique
1. Checking under microscope
2. Returning to surgery
3. Repeat
Which virus is associated with Bowen’s disease?
Which virus is associated with Bowen’s disease?
- HPV 16&18
Signs
- Gottron’s
- Kernig
- Nikolsyiy
- Aspitz
- Koebner
Signs
- Gottron’s
- Dermatomyositis on knuckles - Kernig
- meningitis - Nikolsyiy
- Flacid bullous desquamation - Auspitz
- Pin-point bleeding on psoriasis - Koebner
- Psoriasis at site of trauma
